April 10, 2012

Patients for whom colonoscopy was recommended were less likely to complete colorectal cancer screening than those patients for whom fecal occult blood testing (FOBT) was recommended or those patients who were given a choice between FOBT or colonoscopy, according to a study published in the April 9 issue of Archives of Internal Medicine, a JAMA Network publication.

Colorectal cancer (CRC) is a prevalent condition that can be diagnosed through screening and treated during an asymptomatic phase to prevent the morbidity and mortality associated with the unscreened clinical course of the disease, the authors write in their study background.

John M. Inadomi, M.D., of the University of Washington School of Medicine, Seattle, and colleagues conducted a randomized clinical trial to examine the effects of recommending FOBT, colonoscopy or giving patients at average risk for CRC a choice between the two.

A total of 997 racially and ethnically diverse participants were enrolled in the study conducted in the San Francisco Community Health Network, the public health care system of the city and county of San Francisco. The mean (average) age of participants was 58.4 years and 53 percent of the participants were women.

Within 12 months of enrollment, 58 percent of the participants completed the CRC screening strategy they were assigned or chose. However, a significantly lower proportion of participants in the colonoscopy group completed that procedure (38.2 percent) compared with participants in the FOBT group completing that screening (67.2 percent) or those participants who were allowed to choose their screening (68.8 percent).

"There were significant racial/ethnic differences in screening completion, however, with whites more often completing colonoscopy and nonwhites more often completing FOBT," the authors comment.

African-Americans had the lowest CRC screening completion rate at 48 percent, while Asians at 60.7 percent and Latinos at 62.9 percent had the highest rates, the study results indicate.

The authors note that some of the differences appear to be driven by language preference. Participants who preferred to speak Spanish, Cantonese or Mandarin during their interviews were "significantly more likely" to adhere to CRC screening than participants of the same racial/ethnic groups who preferred to speak English.

"In summary, this study found that limiting the recommendation for CRC screening to colonoscopy can result in a lower completion rate for CRC screening compared with providing a choice between FOBT or colonoscopy, especially among ethnic/racial minorities," the authors conclude.

(Arch Intern Med. 2012;172[7]:575-582. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This work was supported by grants from the National Cancer Institute at the National Institutes of Health, the National Institutes of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, and the National Center for Research Resources at the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an invited commentary, Theodore R. Levin, M.D., of Kaiser Permanente Medical Center, Walnut Creek, Calif., writes: "An important implication of this research is that the notion of 'preferred' CRC screening test should include both the physician's and the patient's perspective."

"If having too many choices leads to confusion, the study by Inadomi et al demonstrates that not having enough choice may lead to inaction when the only choice is colonoscopy. This study also shows that well-informed PCPs (primary care providers), focused on CRC screening, can have a meaningful impact on their patient's adherence with screening," Levin concludes. "When it comes to CRC screening, providing an option other than colonoscopy for our patients is not overwhelming, but necessary."

(Arch Intern Med. 2012;172[7]:582-583. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: The invited commentary was partly funded by a grant from the National Cancer Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.